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Form 1193
Rev.6-15-25
THE AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at foot of page in answering all questions)
1. Name of applicant Miss mary E Williams Badge No.
Address Justegee that, City Fuckage State alabama
2. Age 3 2
3. General physique Good
Height 5 ft 6in. 1 Weight 150 lbs.
4. Tendency to disease, inherited or otherwise none.
5. Previous history in regard to serious illness or surgical operation none.
6. Has she had rheumatism ? No.
7. Has she at present or has she ever had hernia ? no.
8. Condition of teeth good.
9. Condition of Bones and Joints good.
Flat Foot no.
10. Abdomen and contained organs good.
11. Chest and contained organs good.
Girth: Expiration 36inches "inches. Inspiration 39 -
inches
Respiration, rate of
19
Heart, pulse rate normal.
Right eye (Snellen) 20-20 Corrected to nonewased
12. Vision:
Left eye (Spellen) 20-20 Corrected to noneyued
13.
Hearing: Right Food 20-20 Left Good 20-20
Whispering
14. Urine examination
whispering
Color Straw.
Reaction acid.
Specific gravity 1018.
Albumen none. (negative)
Casts none
Leucocytes none.
Sugar none.
15.
Do you recommend applicant for active hospital service? yes,
Josephus G.Carr M. D.
Date
December 13,1926 Address Punkagee Inst. alabama
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
To be forwarded to the Local Committee on Red Cross Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
2. Give age in years, height`i in inches, weight in pounds, stating amount of clothing entering into weight.
8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
9. Flat foot-state whether or not any inconvenience exists.
11. Chest measurements should be in total inches.
12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc. If glasses
are worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.
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Context sent to Scholar
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"ocrText": "Form 1193\nRev.6-15-25\nTHE AMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at foot of page in answering all questions)\n1. Name of applicant Miss mary E Williams Badge No.\nAddress Justegee that, City Fuckage State alabama\n2. Age 3 2\n3. General physique Good\nHeight 5 ft 6in. 1 Weight 150 lbs.\n4. Tendency to disease, inherited or otherwise none.\n5. Previous history in regard to serious illness or surgical operation none.\n6. Has she had rheumatism ? No.\n7. Has she at present or has she ever had hernia ? no.\n8. Condition of teeth good.\n9. Condition of Bones and Joints good.\nFlat Foot no.\n10. Abdomen and contained organs good.\n11. Chest and contained organs good.\nGirth: Expiration 36inches \"inches. Inspiration 39 -\ninches\nRespiration, rate of\n19\nHeart, pulse rate normal.\nRight eye (Snellen) 20-20 Corrected to nonewased\n12. Vision:\nLeft eye (Spellen) 20-20 Corrected to noneyued\n13.\nHearing: Right Food 20-20 Left Good 20-20\nWhispering\n14. Urine examination\nwhispering\nColor Straw.\nReaction acid.\nSpecific gravity 1018.\nAlbumen none. (negative)\nCasts none\nLeucocytes none.\nSugar none.\n15.\nDo you recommend applicant for active hospital service? yes,\nJosephus G.Carr M. D.\nDate\nDecember 13,1926 Address Punkagee Inst. alabama\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\nTo be forwarded to the Local Committee on Red Cross Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n2. Give age in years, height`i in inches, weight in pounds, stating amount of clothing entering into weight.\n8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n9. Flat foot-state whether or not any inconvenience exists.\n11. Chest measurements should be in total inches.\n12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc. If glasses\nare worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc."
}